Search

Introduction: measuring the severity of traumatic injuries is crucial for predicting clinical outcomes. Whereas the Injury Severity Score (ISS) has limitations in assigning scores to injuries at the same site, the New Injury Severity Score (NISS) corrects for this problem by taking into account the three most severe injuries regardless of the region of the body. This study seeks to comprehend the clinical and epidemiological profile of trauma patients while comparing the effectiveness of scales for predicting mortality., Methods: a descriptive, observational and retrospective study using records of patients who underwent thoracotomy at the Hospital das Clínicas of the Federal University of Triângulo Mineiro between 2000 and 2019. Demographic data, mechanisms of injury, affected organs, length of stay and mortality were analyzed. Injury severity was assessed using the ISS and NISS, and statistical analyses were conducted using MedCalc and SigmaPlot., Results: 101 patients were assessed, on average 29.6 years old, 86.13% of whom were men. The average duration of hospitalization was 10.9 days and the mortality rate was 28.7%. The ROC curve analysis revealed a sensitivity of 68.97%, specificity of 80.56% and area under the curve of 0.837 for the ISS, and 58.62%, 94.44% and 0.855 for the NISS, respectively. The Youden index was 0.49 for the ISS and 0.53 for the NISS., Conclusion: the study demonstrated comparable efficacy of NISS and ISS in predicting mortality. These findings hold significance in the hospital setting. Professionals must be familiar with these scales to utilize them competently for each patient.

Introduction: Extensive research relying on Injury Severity Scores (ISS) reports a mortality benefit from routine non-selective thoracic CTs (an integral part of pan-computed tomography (pan-CT)s). Recent research suggests this mortality benefit may be artifact. We hypothesized that the use of pan-CTs inflates ISS categorization in patients, artificially affecting admission rates and apparent mortality benefit., Methods: Eight hundred and eleven patients were identified with an ISS >15 with significant findings in the chest area. Patient charts were reviewed and scores were adjusted to exclude only occult injuries that did not affect treatment plan. Pearson chi-square tests and multivariable logistic regression were used to compare adjusted cases vs non-adjusted cases., Results: After adjusting for inflation, 388 (47.8%) patients remained in the same ISS category, 378 (46.6%) were reclassified into 1 lower ISS category, and 45 (5.6%) patients were reclassified into 2 lower ISS categories. Patients reclassified by 1 category had a lower rate of mortality ( P < 0.001), lower median total hospital LOS ( P < .001), ICU days ( P < .001), and ventilator days ( P = 0.008), compared to those that remained in the same ISS category., Conclusion: Injury Severity Score inflation artificially increases survival rate, perpetuating the increased use of pan-CTs. This artifact has been propagated by outdated mortality prediction calculation methods. Thus, prospective evaluations of algorithms for more selective CT scanning are warranted.

Importance: Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown., Objective: To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers., Design, Setting, and Participants: This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020., Exposure: At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5)., Main Outcomes and Measures: New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites., Results: This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge., Conclusions and Relevance: In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.

Prognostic determinants in thoracic trauma are of major public health interest. We intended to describe patterns of thoracic trauma, demographic factors, clinical course, and predictors of outcome in selected tertiary care hospitals in Sri Lanka. A multicentre prospective cohort study was conducted in five leading teaching hospitals from June to September 2017. Patients with thoracic trauma were followed up during the hospital stay. A logistic regression analysis was conducted using in-hospital morbidity as the dichotomous outcome variable. One hundred seventy-one patients were included in the study yielding 1450 (median = 8.5) person-days of observation. Of them, 71.9% ( n  = 123) were males. The mean age was 45.8 ± 17.9 years. Majority (39.2%, n  = 67) were recruited from the National Hospital of Sri Lanka. Automobile accidents were the commonest (62.6%, n  = 107), followed by falls (26.9%, n  = 46), assaults (8.8%, n  = 15), and animal attacks (1.8%, n  = 3). The ratio of blunt to penetrating trauma was 5.6 : 1. Injury patterns were rib fractures (80.7%, n  = 138), haemothorax (44.4%, n  = 76), pneumothorax (44.4%, n  = 76), lung contusion (22.8%, n  = 39), flail segment (15.8%, n  = 27), tracheobronchial trauma (7.0%, n  = 12), diaphragmatic injury (2.3%, n  = 4), vascular injury (2.3%, n  = 4), cardiac contusions (1.1%, n  = 2), and oesophageal injury (0.6%, n  = 1). Ninety nine (57.9%) had extrathoracic injuries. Majority (63.2%, n  = 108) underwent operative management including intercostal tube insertion (60.8%, n  = 104), wound exploration (6.4%, n  = 11), thoracotomy (4.1%, n  = 7), rib reconstruction (4.1%, n  = 7), and video-assisted thoracoscopic surgery (2.9%, n  = 5). Pneumonia (10.5%, n  = 8), bronchopleural fistulae (2.3%, n  = 4), tracheaoesophageal fistulae (1.8%, n  = 3), empyema (1.2%, n  = 2), and myocardial infarction (1.2%, n  = 2) were the commonest postoperative complications. The mean hospital stay was 15.6 ± 18.0 days. The in-hospital mortality was 11 (6.4%). The binary logistic regression analysis with five predictors (age, gender, mechanism of injury (automobile/fall/assault), type of trauma (blunt/penetrating), and the presence of extrathoracic injuries) was statistically significant to predict in-hospital morbidity ( X 2 (6, n  = 168) = 13.1; p =0.041), explaining between 7.5% (Cox and Snell R 2 ) and 14.5% (Nagelkerke R 2 ) of variance. The automobile accidents (OR: 2.3, 95% CI = 0.2-26.2) and being males (OR: 2.3, 95% CI = 0.6-9.0) were the strongest predictors of morbidity., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2020 Yasith Mathangasinghe et al.)

Blunt chest wall injuries are a significant cause of mortality and morbidity in trauma patients. Accurate identification and description of chest wall injuries by the radiologist can aid in guiding proper patient management. The American Association for the Surgery of Trauma (AAST) has devised a classification system based on severity. This article describes the features of each injury grade according to the AAST injury scale and discusses the implications for management. Additionally, common mechanisms of blunt chest trauma and multimodal imaging techniques are discussed.

Objective: to evaluate epidemiology, anatomical characteristics, management, and prognosis of critical patients with sternum fractures., Methods: retrospective analysis of patients admitted to intensive care unit (ICU) of a Level III trauma center in Sao Paulo, Brazil., Results: 1552 trauma patients were admitted from January 2012 to April 2016. A total of 439 patients had thoracic trauma and among these, 13 patients had sternum fracture, making up 0.9% of all trauma admissions and 3% of all thoracic trauma cases. Three of these 13 patients had unstable chest, two underwent surgical management for fracture fixation, and three died (mortality was of 29%). In one of the deaths, sternum fracture was assessed as the main contributor to the outcome., Conclusion: sternum fracture was diagnosed in 0.9% of critical trauma patients in a specialized ICU. Only 15% of patients required specific surgical management in the acute phase. In most cases, mortality was due to other injuries.

Slipping rib syndrome is an often unrecognized and underdiagnosed condition caused by the increased mobility of the anterior ends of the costal cartilages of the false ribs. Patients usually present with severe intermittent abdominal pain that is exacerbated by various physical movements. Diagnosis of slipping rib syndrome is mainly clinical and can be confirmed by a physical examination technique termed the "Hooking Maneuver." Treatment includes conservative therapy, intercostal nerve block and surgical operation. Hence, the management and care plan of each patient must be individualized as per the presenting symptoms and medical history. Early recognition and prompt intervention necessitate that physicians be more aware of the symptomatology and prognosis of this condition. This study presents a rare case of a patient with slipping rib syndrome and offers medical insight to the clinical diagnosis and therapeutic modalities of this condition, in light of the current existing literature., (Copyright © 2018. Published by Elsevier Inc.)

Objective: to determine the frequency of fatal cardiac trauma in the city of Manaus, Brazil, between November 2015 and October 2016, and to clarify the mechanisms of trauma and death, previous hospital treatment, as well as the injuries associated with cardiac trauma., Methods: retrospective, observational, and cross-sectional study, which reviewed the necropsy reports of individuals whose cause of death was cardiac injury., Results: the cardiac trauma rate was of 5.98% (138 cases) out of 2,306 necropsies performed in the study period by Instituto Médico Legal (IML) de Manaus (IML is a Brazilian institute responsible for necropsies and cadaveric reports). Males accounted for 92% of the cases. The median age was 27 years (14-83). Gunshot wounds (GSW) was the trauma mechanism in 62.3% and stab wound (SW) in 29.7%. Exsanguination was responsible for most of the deaths and cardiac tamponade was present in second place. On-site death occurred in 86.2% of the cases. The ventricles were the most common site of cardiac injury. Hemothorax was identified in 90.6% of the individuals. Only 23 patients (16.7%) were taken to the hospital (Emergency Room), but six (26.2%) were submitted only to chest drainage, not to thoracotomy. The lung was unilaterally affected in 57% of the cases and bilaterally in 43%., Conclusion: fatal cardiac trauma represented an index of 5.98% in the city of Manaus. Most patients die at the scene of the trauma, usually due to exsanguination caused by gunshot wound. About a quarter of patients who reached the hospital and died were not diagnosed with cardiac trauma in time.

Background: Trauma is the leading cause of death in young patients and thoracic trauma (TT) is responsible for 25-35% of trauma deaths., Aim: To describe and compare features, trauma severity indexes and morbidity of patients admitted for TT in the past three decades., Material and Methods: Review of a TT database, operative notes and medical records of patients. These were separated by decade of admission (1981-1990, 1991-2000, 2001-2010). TT characteristics were compared. Injury Severity Score (ISS), Revised Trauma Score (RTS-T) and Trauma Injury Severity Score (TRISS) were calculated., Results: A total of 3,068 TT were reviewed. In the 1981-1990 period, 604 cases of TT were registered (19.7%), in the 1991-2000 period, 1,070 cases (34.9%) and in the 2001-2010 period, 1,394 cases (45.4%) (p < 0.05). The ages of patients in each of these periods were 34.9 ± 15.5, 33.9 ± 16.2 and 35.7 ± 18.2 years respectively (p < 0.05). The proportion of patients aged 65 years or more were 6.6, 7.7 and 10.1% respectively, the proportion of females was 6.1, 9.4 and 12.0%, respectively. The causing agents per decade were knife wounds in 51.5, 61.1 and 60.0% of cases respectively, firearms in 2.5, 3.3 and 5.0% of cases respectively, multiple trauma in 13.9, 14.5 and 9.0% respectively and morbidity in 18.7, 19.7 and 11.7%, respectively. The ISS per decade was 11.9 ± 6.5, 12.9 ± 6.9 and 10.4 ± 6.8 respectively. No significant difference were found in mortality (1.5, 3.0, 2.0% respectively) or TRISS score (2.7, 3.2 and 3.8% respectively)., Conclusions: An increase in the number of hospital admission for TT has occurred in the last three decades, with an increase in the proportion of admissions of subjects aged 65 years or more, females and with firearm injuries.

Background: Despite increases in imaging guidelines for other body-regions during initial trauma assessment and the demonstrated utility of chest radiographs (CXR), guidelines for use of thoracic computed-tomography (TCT) are lacking. We hypothesized that TCT utilization had not decreased relative to other protocolized CTs, and mechanism and CXR could together predict significant injury independent of TCT., Methods: We performed a retrospective review of blunt trauma patients ≤18 y.o. (2007-2015) at two level-1 trauma centers who received chest imaging. Baseline characteristics and incidences of body region-specific CT were compared. Injury mechanism, intrathoracic pathology, and interventions among other data were examined (significance: p<0.05)., Results: Although other body-region CT incidence decreased (p<0.05), TCT incidence did not change (p=0.65). Of the 2951 patients, 567 had both CXR and TCT, 933 received TCT-only, and 1451 had CXR-only. TCT altered management in 17 patients: 2 operations, 1 stent-placement, 1 medical management, 9 thoracostomy tube placements, and 4 negative diagnostic workups. All clinically significant changes were predicted by vehicle-related mechanism and abnormal CXR findings., Conclusions: TCT utilization has not decreased over time. All meaningful interventions were predicted by CXR and mechanism of injury. We propose a rule, for prospective validation, reserving TCT for patients with abnormal CXR findings and severe vehicle-related trauma., Level of Evidence: Diagnostic study, Level III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Traumatic aortic injury (TAI) is a rare but life-threatening type of injury. We investigate whether the anatomy of the aortic arch influences the severity of aortic injury., Methods: This is a retrospective study of twenty-two cases treated with TEVAR for TAI in our department from 2009 to 2014. Aortic injury was assessed in accordance with the recommendations of the Society of Vascular Surgery. We measured the aortic arch angle and the aortic arch index, based on the initial angio-CT scan, in each of the analyzed cases., Results: The mean aortic arch index and mean aortic arch angle were 6.8 cm and 58.3°, respectively, in the type I injury group; 4.4 cm and 45.9° in the type III group; 3.3 cm and 37° in the type IV group. There were substantial differences in both the aortic arch index and the aortic arch angle of the type III and IV groups. A multivariate analysis confirmed that the aortic arch angle was significantly associated with the occurrence of type III damage (OR 1.5; 95% CI 1.03-2.2)., Conclusions: The severity of TAI is influenced by the sharpness of the aortic arch. There is an inverse relationship between the severity of aortic injury and the aortic arch index., Competing Interests: The authors declare no conflicts of interest in association with the present study.

Study Objective: The NEXUS chest decision instrument identifies a very-low-risk population of patients with blunt trauma for whom chest imaging can be avoided. However, it requires that all 7 National Emergency X-Ray Utilization Study (NEXUS) chest criteria be absent. To inform patient and physician shared decisionmaking about imaging, we describe the test characteristics of individual criteria of the NEXUS chest decision instrument and provide the prevalence of injuries when 1, 2, or 3 of the 7 criteria are present., Methods: We conducted this secondary analysis of 2 prospectively collected cohorts of patients with blunt trauma who were older than 14 years and enrolled in NEXUS chest studies between December 2009 and January 2012. Physicians at 9 US Level I trauma centers recorded the presence or absence of the 7 NEXUS chest criteria. We calculated test characteristics of each criterion and combinations of criteria for the outcome measures of major clinical injuries and thoracic injury observed on chest imaging., Results: We enrolled 21,382 patients, of whom 992 (4.6%) had major clinical injuries and 3,135 (14.7%) had thoracic injuries observed on chest imaging. Sensitivities of individual test characteristics ranged from 15% to 56% for major clinical injury and 14% to 53% for thoracic injury observed on chest imaging, with specificities varying from 71% to 84% for major clinical injury and 67% to 84% for thoracic injury observed on chest imaging. Individual criteria were associated with a prevalence of major clinical injury between 1.9% and 3.8% and of thoracic injury observed on chest imaging between 5.3% and 11.5%., Conclusion: Patients with isolated NEXUS chest criteria have low rates of major clinical injury. The risk of major clinical injury for patients with 2 or 3 factors range from 1.7% to 16.6%, depending on the combination of criteria. Criteria-specific risks could be used to inform shared decisionmaking about the need for imaging by patients and their physicians., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Blunt aortic injuries (BAIs) are traditionally treated as surgical emergencies, with the majority of repairs performed in an urgent fashion within 24 hours, irrespective of the grade of aortic injury. These patients are often underresuscitated and often have multiple other trauma issues that need to be addressed. This study reviews a single center's experience comparing urgent (<24 hours) thoracic endovascular aneurysm repair (TEVAR) versus delayed (>24 hours) TEVAR for Grade III BAI., Methods: All patients undergoing TEVAR for BAI at a single institution between March 2004 and March 2014 were reviewed (n = 43). Patients with Grade I, II, or IV aortic injuries as well as those who were repaired with an open procedure or who lacked preoperative imaging were excluded from the analysis. Demographics, intraoperative data, postoperative survival, and complications were compared., Results: During this period, there were 43 patients with blunt thoracic aortic injury. There were 29 patients with Grade III or higher aortic injuries. Of these 29 patients, 1 declined surgery, 2 were repaired with an open procedure, 10 underwent urgent TEVAR, and 16 had initial observation. Of these 16, 13 underwent TEVAR in a delayed fashion (median, 9 days; range, 2-91 days), and 3 died of non-aortic-related pathology. Comparing the immediate repair group versus the delayed repair group, there were no significant demographic differences. Trauma classification scores were similar, although patients in the delayed group had a higher number of nonaortic injuries. The 30-day survival was similar between the two groups (9 of 10 vs. 12 of 16), with no mortalities caused by aortic pathology in either group., Conclusion: Watchful waiting may be permissible in patients with Grade III BAI with other associated multisystem trauma. This allows for a repair in a more controlled environment., Level of Evidence: Therapeutic study, level V.

In polytrauma patients a thoracic trauma is one of the most critical injuries and an important trigger of post-traumatic inflammation. About 50% of patients with thoracic trauma are additionally affected by bone fractures. The risk for fracture malunion is considerably increased in such patients, the pathomechanisms being poorly understood. Thoracic trauma causes regional alveolar hypoxia and, subsequently, hypoxemia, which in turn triggers local and systemic inflammation. Therefore, we aimed to unravel the role of oxygen in impaired bone regeneration after thoracic trauma. We hypothesized that short-term breathing of 100% oxygen in the early post-traumatic phase ameliorates inflammation and improves bone regeneration. Mice underwent a femur osteotomy alone or combined with blunt chest trauma 100% oxygen was administered immediately after trauma for two separate 3 hour intervals. Arterial blood gas tensions, microcirculatory perfusion and oxygenation were assessed at 3, 9 and 24 hours after injury. Inflammatory cytokines and markers of oxidative/nitrosative stress were measured in plasma, lung and fracture hematoma. Bone healing was assessed on day 7, 14 and 21. Thoracic trauma induced pulmonary and systemic inflammation and impaired bone healing. Short-term exposure to 100% oxygen in the acute post-traumatic phase significantly attenuated systemic and local inflammatory responses and improved fracture healing without provoking toxic side effects, suggesting that hyperoxia could induce anti-inflammatory and pro-regenerative effects after severe injury. These results suggest that breathing of 100% oxygen in the acute post-traumatic phase might reduce the risk of poorly healing fractures in severely injured patients.

A comprehensive analysis is performed to evaluate the effect of weight, height and body mass index (BMI) of occupants on side impact injuries at different body regions. The accident dataset for this study is based on the National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) for accident year 2000-08. The mean BMI values for driver and front passenger are estimated from all types of crashes using NASS database, which clearly indicates that mean BMI has been increasing over the years in the USA. To study the effect of BMI in side impact injuries, BMI was split into three groups namely (1) thin (BMI<21), (2) normal (BMI 24-27), (3) obese (BMI>30). For more clear identification of the effect of BMI in side impact injuries, a minimum gap of three BMI is set in between each adjacent BMI groups. Car model years from MY1995-1999 to MY2000-2008 are chosen in order to identify the degree of influence of older and newer generation of cars in side impact injuries. Impact locations particularly side-front (F), side-center (P) and side-distributed (Y) are chosen for this analysis. Direction of force (DOF) considered for both near side and far side occupants are 8 o'clock, 9 o'clock, 10 o'clock and 2 o'clock, 3 o'clock and 4 o'clock respectively. Age <60 years is also one of the constraints imposed on data selection to minimize the effect of bone strength on the occurrence of occupant injuries. AIS2+ and AIS3+ injury risk in all body regions have been plotted for the selected three BMI groups of occupant, delta-V 0-60kmph, two sets (old and new) of car model years. The analysis is carried with three approaches: (a) injury risk percentage based on simple graphical method with respect to a single variable, (b) injury distribution method where the injuries are marked on the respective anatomical locations and (c) logistic regression, a statistical method, considers all the related variables together. Lower extremity injury risk appears to be high for thin BMI group. It is found that BMI does not have much influence on head injuries but it is influenced more by the height of the occupant. Results of logistic analysis suggest that BMI, height and weight may have significant contribution towards side impact injuries across different body regions., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: The effects of age, body mass index (BMI) and gender on motor vehicle crash (MVC) injuries are not well understood and current prevention efforts do not effectively address variability in occupant characteristics., Objectives: (1) Characterize the effects of age, BMI and gender on serious-to-fatal MVC injury. (2) Identify the crash modes and body regions where the effects of occupant characteristics on the numbers of occupants with injury is largest, and thereby aid in prioritizing the need for human surrogates that represent different types of occupant characteristics and adaptive restraint systems that consider these characteristics., Methods: Multivariate logistic regression was used to model the effects of occupant characteristics (age, BMI, gender), vehicle and crash characteristics on serious-to-fatal injuries (AIS 3+) by body region and crash mode using the 2000-2010 National Automotive Sampling System (NASS-CDS) dataset. Logistic regression models were applied to weighted crash data to estimate the change in the number of annual injured occupants with AIS 3+ injury that would occur if occupant characteristics were limited to their 5th percentiles (age≤17 years old, BMI≤19kg/m(2)) or male gender., Results: Limiting age was associated with a decrease in the total number of occupants with head [8396, 95% CI 6871-9070] and thorax injuries [17,961, 95% CI 15,960-18,859] across all crash modes, decreased occupants with spine [3843, 95% CI 3065-4242] and upper extremity [3578, 95% CI 1402-4439] injuries in frontal and rollover crashes and decreased abdominal [1368, 95% CI 1062-1417] and lower extremity [4584, 95% CI 4012-4995] injuries in frontal impacts. The age effect was modulated by gender with older females more likely to have thorax and upper extremity injuries than older males. Limiting BMI was associated with 2069 [95% CI 1107-2775] fewer thorax injuries in nearside crashes, and 5304 [95% CI 4279-5688] fewer lower extremity injuries in frontal crashes. Setting gender to male resulted in fewer occupants with head injuries in farside crashes [1999, 95% CI 844-2685] and fewer thorax [5618, 95% CI 4212-6272], upper [3804, 95% CI 1781-4803] and lower extremity [2791, 95% CI 2216-3256] injuries in frontal crashes. Results indicate that age provides the greater relative contribution to injury when compared to gender and BMI, especially for thorax and head injuries., Conclusions: Restraint systems that account for the differential injury risks associated with age, BMI and gender could have a meaningful effect on injury in motor-vehicle crashes. Computational models of humans that represent older, high BMI, and female occupants are needed for use in simulations of particular types of crashes to develop these restraint systems., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

It analyzed the diagnosis and treatment results of 123 patients with cervicothoracic injuries for 21 years. The frequency of cervicothoracic injuries among all patients with cervical injuries was 5.7%. Preoperative and postoperative diagnosis included radial and endoscopic methods. The complications rate was 43.6%. The most severe complications were observed in patients with delayed diagnosis of trachea and esophagus injuries.

Pediatric trauma is commonly encountered in the emergency department, and trauma to the head, chest, and abdomen may be a source of significant morbidity and mortality. As children have unique thoracic anatomical and physiological properties, they may present with diagnostic challenges that the emergency clinician must be aware of. This review examines the effects of blunt trauma to the pediatric chest, as well as its relevant etiologies and associated mortality. Diagnostic and treatment options for commonly encountered injuries such as pulmonary contusions, rib fractures, and pneumothoraces are examined. Additionally, this review discusses rarely encountered--yet highly lethal--chest wall injuries such as blunt cardiac injuries, commotio cordis, nonaccidental trauma, and aortic injuries.

Introduction: Isolated thoracic injuries are relatively common and they are on the second place as a cause of death overall trauma. Most patients with isolated thoracic injuries are treated on an outpatient basis while only serious cases are hospitalized. The basis of the treatment of thoracic trauma is efficient cardiopulmonary reanimation followed by an early detection and treatment of life threatening injuries. Less than 15% of patients with thoracic trauma require thoracotomy., Patients: Only the patients with exclusively isolated thoracic trauma were analyzed., Results: Based on initial diagnostic procedures initial conservative treatment was indicated and sufficient for 63.75% (204/320) cases while initial surgery treatment was necessary in 36.25% (116/320) of the injured. In relation to the type of surgery the thoracic drainage was performed in 81.03% (94/116) while thoracotomy and VATS procedure was necessary for 7.75% (9/116) of the injured. After the secondary examination or shorter monitoring of the status of the injured, the additional diagnostic procedure was suggested and performed in only 5% (16/320) of the injured. The average period of the hospitalization for all injured with isolated thoracic trauma was 5.9 +/- 4.0 days (from 6 hours to 16 days). In cases of patients with blunt injuries the average period of hospitalization was 6.07 +/- 4.26 days, while for the patients with penetrating trauma it was 5.4 +/- 3.36 days. The calculated value oft-student test (0.2766 > 0.05) indicates that there is no statistically significant difference in the period of the hospitalization in relation to the type of trauma (blunt vs. penetrating). The average period of thoracic drainage was 5.58 +/- 3.3 days (from 3 to 17 days). The average duration of thoracic drainage in the patients with blunt trauma was 5.81 +/- 2.67 days, while in the patients with penetrating trauma it was 5.08 +/- 1.99 days. The calculated value of the probability of t-test (0.1478 > 0.05) shows that there is no significant difference in the period of drainage in cases of blunt and penetrating trauma. Out of total number of patients, 98.0% (315/320) of the injured were successfully treated. The complications were found in 1.25% (4/320) cases. Death was the outcome in 1.5% (5/320) of injured., Conclusion: Based on the results of the initial diagnostic treatment, in majority of injured with isolated thoracic trauma, it was possible to conduct the relevant and appropriate therapeutic procedures. On the basis of relatively short period of thoracic drainage, hospitalization and low rates of morbidity and mortality, it may be confirmed that the application of initial diagnostic and therapeutic protocols of the Clinic for thoracic surgery resulted in the achievement of the successful treatments in majority of the injured for this type of the

232 cases of septic complications after penetrating thoracic injury were analyzed. All patients were divided into groups according to the injury mechanism and inhabitancy. Patients with medico-social deviations, as well as patients with hemocontact infections, mental insanity and social deviations were marked out. 75% of patients were reported to have any medico-social deviations. Among them the distributing was as follows: persons with no fixed abode (100%), women (91%), patients over 50 years (86.2%) and patients after knife thoracic injury (77.4%). Among patients with hemocontact infection the majority were incomers from the near-abroad countries (37%), victims of assault (20%) and patients aged 31-40 years (18.4%).

Quantifying or, more generally, estimating the severity of the possible consequences of occupational accidents is a decisive step in any occupational risk assessment process. Because of the lack of historic information (accident data collection and recording are incipient and insufficient, particularly in construction) and the lack of practical tools in the construction industry, the estimation/quantification of occupational accident severity is a notably arbitrary process rather than a systematic and rigorous assessment. This work proposes several severity functions (based on a safety risk assessment) to represent biomechanical knowledge with the aim of determining the severity level of occupational accidents in the construction industry and, consequently, improving occupational risk assessment quality. We follow a fuzzy approach because it makes it possible to capture and represent imprecise knowledge in a simple and understandable way for users and specialists., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

The authors presented results of examination and treatment of 1347 patients with different injuries of the chest and abdomen. Medico-diagnostic measures used in treatment of such kind of patients with rational application of endovideosurgical techniques such as thoraco- and laparoscopy are described which proved to be the final kind of operative treatment.

An ideal injury criterion should be predictive of the risk of injury across the range of loading conditions where it may be applied. The injury risk curve associated with this criterion should be applicable to all loading conditions. With respect to side impact, the injury risk curve should apply to pure lateral or oblique loading by rigid and padded walls, as well as airbags. Trosseille et al. (2009) reported that the number of fractured ribs was higher in pure lateral impact than in forward oblique interaction with an airbag. A good dummy criterion should be able to account for this difference. To evaluate various injury criteria with the WorldSID 50 th and ES-2re dummies, the dummies were exposed to the same airbag loadings as the PMHS. The criteria measured in the dummy tests were paired with the rib fractures from the PMHS tests. Regarding the effect of configuration, results of sled tests with the 50 th percentile WorldSID (Petitjean, 2009) and ES-2re (Kuppa, 2003) have been paired with injuries found in the PMHS tested in the same conditions. The relationships obtained were compared with the relationships established in the same way for the subjects loaded in the airbag tests. Comparing the lateral and oblique lateral loading conditions, both the WorldSID and the ES-2re exhibited differences in peak lateral deflection of their ribs that were consistent with the different number of rib fractures for PMHS subjected to these loading conditions. For each dummy, the risk of rib fractures could be assessed from one injury risk curve, regardless of the loading angle. Furthermore, the same injury risk curve can be used to assess the risk of rib fractures from sled tests and airbag loading. However, because the WorldSID deflection measurements differed in the rigid and padded sled tests, it is recommended that the dummy's sensitivity to padding be further assessed prior to adopting injury risk curves for WorldSID. Rib deflections of the ES- 2re were not sensitive to padding. Finally, VC should not be considered as a valid criterion to assess the risk of rib fractures.

Background: The significance of serial white blood cell (WBC) counts in trauma patients with a suspected hollow viscus injury (HVI) is unknown. The purpose of this study was to examine the role of serial WBC counts in the diagnosis of a HVI., Methods: After institutional review board approval, all injured patients admitted to a Level I trauma center from January 2003 to December 2007 with at least one WBC measurement were included in a retrospective analysis. The WBC profiles for patients with a HVI were compared against those without HVI. All WBC counts are reported as [x10(3)/microL]., Results: The mean WBC count of the overall study population (n = 5,950) on admission was 11.6 +/- 5.3. Overall, 59.2% had an elevated WBC count on admission. A significant relationship between increasing Injury Severity Score and increasing WBC count on admission was found by linear regression. When comparing patients with HVI (n = 267) with patients without HVI (n = 5,683), no significant difference was found for admission WBC count. The highest WBC count within the first 24 hours for patients with HVI was 16.7 +/- 4.7. This was significantly higher than that for the 4,520 patients without any intraabdominal injury (13.0 +/- 5.2, adjusted p < 0.001). Penetrating injury, a concomitant severe thoracic trauma (chest Abbreviated Injury Scale value >or=3), and highest WBC count >or=20.0 in the first 24 hours were independent risk factors for HVI. A maximal WBC count or=20.0 are independently associated with a HVI, whereas counts

Previous parts to this series on thoracic and neck trauma discussed the anatomy and physiology of the thorax, assessment and initial nursing interventions, imaging and adjuncts to diagnosis. Part 2 describes specific chest wall and lung injuries, types of pneumothoraces and their diagnosis and management. This section, part 3 of 4, discusses other types of thoracic injuries and their management, such as trauma to the diaphragm and heart., (Crown Copyright 2010. Published by Elsevier Ltd. All rights reserved.)

The article presents an overall estimate of experience of surgical treatment of ballistic penetrating wounds of bosom of 1920 wounded in Afgan war (1979-1989) and 367 wounded during the armed conflict on Northern Caucasus (1994-1996). Ballistic penetrating wounds of bosom in modern military conflicts are characterized by high mortality on battle field, achieving 30%. In conditions of heavy wound the choice of optimum surgery tactics poses several difficulties, and due to it indications urgent thoracotomy are often increased. Multistage system of delivery of health care, used in Afgan war, during battle actions on the Northern Caucasus was changed to 2-stage system, where wounded persons during 1-2 hours were delivered to a specialist in multiprofile base hospital, placed in a combat zone. Effectuating of thoracocentesis with a closed drainage of pleural space stays the most popular and extended method of treatment ballistic penetrating wounds of bosom, used by 85% of wounded persons. Using of operative videothoracoscopia in 1995 during delivery of emergency specialized surgical medical care to wounded persons in forward base hospital leaded to decreasing of frequency of using of large thoracotomy to 2,4%. There was overviewed the modern conception of surgical treatment of patients, having bosom wounds.

79 patients with gunshot bullet wounds of thorax and abdomen were observed. Thoracoabdominal wounds were observed in 37 cases, abdominothoracic wounds - in 35 cases. 7 cases of longitudinal non-penetrating thoracic and abdominal wounds were particularly investigated. The wound canal started in soft tissues of anterior thoracic wall and passed through the thick layers of anterior abdominal wall to the perineum. Lateral blow due to high kinetic energy of bullets caused severe damage of the ribs, lungs and abdominal organs without diaphragm lesions.

Aim: Paediatric chest trauma is a marker of severe injury and a significant cause of morbidity and mortality. However, current trends in the Australian population are unknown. This study aims to outline the profile and management of major paediatric chest trauma in Victoria., Methods: Prospectively collected data of patients from the Victorian State Trauma Registry from July 2001 to June 2007 were retrospectively reviewed. Data on fatalities were obtained from the National Coroners Information System. Descriptive statistics were used to summarise the profiles of major trauma cases and coroners' cases., Results: Overall, 204 cases with serious paediatric chest injuries were reported by the Victorian State Trauma Registry (n = 158) and National Coroners Information System (n = 46) (excluding overlapping cases) in 2001-2007. Paediatric chest trauma was more common in males. The Injury Severity Score ranged from 16 to 25 in most patients. Blunt trauma was responsible for 96% of cases, of which motor vehicle collisions accounted for 75%. Median hospitalisation was 9 days, and 64% of patients were admitted to intensive care. Common injuries included lung contusion (66%), haemo/pneumothorax (32%) and rib fracture (23%). Multiple organ injury occurred in 99% of cases, with head (62%) and abdominal (50%) injury common. Management was conservative, with only 11 cases (7%) treated surgically. The highest mortality was in the 10-15-year age group. In 52 (79%) fatalities, injury was transport related., Conclusion: Australian paediatric chest trauma trends are similar to international patterns. Serious injury requiring surgical intervention is rare. This limited exposure may lead to difficulty in maintaining surgical expertise in this highly specialised area.

Thoracolumbar injuries usually are the result of high-energy trauma and frequently are associated with multisystem concomitant injuries. Whenever a thoracolumbar injury is suspected, a prompt and thorough evaluation should be performed in the emergency department, using the guidelines of the American College of Surgeons and including full primary and secondary surveys as well as resuscitation. Protection of the spine and spinal cord is of paramount importance during the initial evaluation. A careful and complete neurologic examination is warranted as part of the secondary survey. Plain radiography, CT, and MRI studies are useful in diagnosing and classifying thoracolumbar injuries. At many trauma centers, CT has become the standard imaging technology for the initial evaluation of the spine. MRI is particularly accurate in detecting injury to the posterior ligamentous complex of the thoracolumbar spine. Classification and treatment of thoracolumbar injuries are controversial. The comprehensive, reproducible classification system of the Spine Trauma Study Group has prognostic significance and can guide treatment decisions. The Thoracolumbar Injury Classification and Severity scale classifies thoracolumbar injures based on three pivotal characteristics: the morphology of the injury, the integrity of the posterior ligamentous complex, and the patient's neurologic status. A total severity score is used in conjunction with the classification system to determine the treatment.

Background: Higher mortality in elderly drivers involved in motor vehicle collisions (MVCs) is a major concern in an aging population. We examined a spectrum of age-related differences in injury severity, outcome, and patterns of injuries using our institution's trauma registry and the National Trauma Data Bank., Methods: Injury severity scores (ISSs) and measures of outcome were compared among five age groups (<26, 26-39, 40-54, 55-69, 70+ years) using chi tests and analysis of variance. International Classification of Diseases-9th Revision (ICD-9) codes were used to compute the frequency of specific injuries across groups. We used stratified analysis and multiple logistic regression to control for confounding., Results: After the age of 25, injury severity, mortality, and length of stay (LOS) all increased progressively with age, whereas likelihood of discharge home decreased for each group (p < 0.001). Restraint use increased with age. However, age-related adverse outcomes were significantly increased even after adjusting for restraint use (p < 0.0001). Unrestrained elderly drivers had the highest mortality and morbidity (p < 0.001), and were least likely to be discharged home (p < 0.001). Abbreviated Injury Scale scores and ICD-9 codes indicated that poor outcomes with older age were driven primarily by head and chest injuries, especially intra-cranial hemorrhage, rib fractures, pneumothorax, and injury to the heart and lungs., Conclusions: Elderly drivers involved in MVCs have disproportionately poor outcomes primarily because of a greater incidence of head and chest injuries. Seat belt and airbag use in elderly drivers significantly reduce this trend but do not eliminate it. These observations should help establish clinical guidelines for the evaluation of traumatized elderly drivers, develop specific education programs, and safer vehicle design.

Three-point restraint systems have been installed in vehicles since the early 1960s. However, it wasn't until the automatic protection rule became effective for 1987 Model Year vehicles that manufacturers began installing 3-point restraints with force-limiting shoulder belts and frontal airbags for the driver and right front passenger. This was the first time that all vehicle manufacturers had to certify that their cars would meet the 50th percentile, adult male protection requirements in the 48 km/h frontal, rigid-barrier test specified in FMVSS 208. To assess the effectiveness of these certified 3-point restraint systems, a search was done of the 1988-2005 NASS data for 3-point belted, front outboard-seated, adult occupants in passenger vehicles that were equipped with airbags and that were involved in frontal, towaway collisions. These data showed that i) half of the occupants with AIS > or = 3 chest injuries were in collisions with a DeltaV < or = 40 km/h; ii) for older occupants (50+ years), half experienced their chest injuries at DeltaVs < or = 34 km/h; and iii) the chest injury rate for the older occupants was more than double that of the younger occupants. An analysis was done to estimate the effectiveness of various levels of shoulder belt limit loads in reducing chest injuries to older occupants. The result of the analysis indicated that a 2.5 kN shoulder belt limit load would substantially reduce shoulder belt-induced AIS > or = 3 chest injuries in 99 percent of frontal collisions to all adult, front outboard seated occupants whose normalized bone strengths are greater than 0.4.

Background/purpose: Predictors of mortality in blunt chest trauma patients have mostly been studied by univariate analysis. This study used multivariate analysis to identify the independent predictors in these patients admitted to a surgical intensive care unit (SICU)., Methods: One hundred and twenty-seven blunt thoracic trauma patients consecutively admitted to a SICU were enrolled and evaluated by quantified injury severity scores including Acute Physiology and Chronic Health Evaluation II (APACHE II), Glasgow Coma Scale (GCS), Therapeutic Intervention Scoring System (TISS) and Injury Severity Score (ISS). Incidence of thoracic and extrathoracic injuries, transfusion and resuscitation volumes, PaO2/FIO2 ratio and the presence of shock were also evaluated., Results: In the univariate analysis, clinical characteristics of survivors (n = 113) and non-survivors (n = 14) at admission were similar regarding age, gender, incidence of intrathoracic injuries and extrathoracic injuries and ISS. The following variables were higher for non-survivors: APACHE II score, 19 +/- 6 vs.12 +/- 6 (p = 0.002); TISS points, 39 +/- 13 vs. 29 +/- 15 (p = 0.019); the presence of shock, 93% vs. 42% (p < 0.001). Non-survivors also had lower GCS, 8 +/- 5 vs.14 +/- 3 (p < 0.001), and PaO2/FIO2 ratio, 211 +/- 124 vs. 340 +/- 145 (p = 0.002). Of the shock patients, they had significantly higher volumes of blood transfusions and fluid resuscitations (p < 0.001) and a higher incidence of abdominal injuries (p = 0.031) and mortality rate (p < 0.001) than non-shock patients. Multivariate logistic regression analysis identified three independent risk factors of mortality: GCS (adjusted odds ratio [OR], 0.76; 95% confidence interval [CI], 0.64-0.89; p = 0.001), PaO2/FIO2 ratio (adjusted OR, 0.75; 95% CI, 0.58-0.98; p = 0.036) and shock (adjusted OR, 3.8; 95% CI, 1.24-11.69; p = 0.020)., Conclusion: Blunt chest trauma was usually associated with injuries of other organ systems, especially of the abdomen and head. Besides a decreased PaO2/FIO2, a lower GCS and a presence of shock were also independent prognostic predictors of mortality for these patients admitted to the ICU.

The authors propose morpho-functional and medico-strategy classification of mechanical injuries of the chest. In addition to traditional principles, special attention is given to concurrency, plurality, possible shocks, domination of the injuries as one of the basic concepts of wound dystrophy. The proposed classifications of mechanical injuries of the chest substantially supplement traditional principles, allow not only correct and full diagnosing and decision on the most rational strategy of treatment of patients with combined traumas, but also give a complex of reliable criteria for a scientific generalization of the results of clinical investigations.

Objective: To analyze the data of trauma patients with thoracic injury in the earthquake of Bam admitted to hospitals of Tehran University of Medical Science (TUMS) for better understanding the type and consequence of thoracic injuries in a major earthquake., Methods: After Bam earthquake registering 6.5 on the Richter scale, 526 trauma patients were admitted to hospitals of TUMS. Among them, 53 patients sustained thoracic injury., Results: This group was composed of 21 females (39.6%) and 32 males (60.4%). Fifteen patients (28.3%) had isolated chest injuries. Rib fracture (36.4%) was the most common injury in our patients and haemo/pneumothorax (25.5%) followed. Superficial injury was the most common accompanying injury. Multiple-trauma patients with chest injury had higher injury severity score (ISS) versus patients with isolated chest injury (P=0.003)., Conclusions: Chest wall injuries and haemo/pneumothorax comprise a considerable number of injuries in survival victims of earthquakes. Consequently, the majority of these patients can be treated with observation or tube thoracostomy. We should train and equip the health workers and members of rescue teams to treat and manage these patients in the field.

Objective: To classify the predominant pattern of injuries following blunt and penetrating chest trauma and to assess the adequacy of treatment strategies, complications and mortality associated with such injuries., Design: Descriptive study., Place and Duration of Study: Surgical Unit I, Holy Family Hospital, Rawalpindi, from December 2000 to December 2003., Patients and Methods: One hundred consecutive patients with thoracic trauma either blunt or penetrating, admitted in the ward were evaluated. Their injuries were classified, treatment strategies outlined and complications and mortality were documented on a specially-designed proforma., Results: Out of the 100 patients presenting in emergency, 44% presented with blunt and 56% with penetrating trauma. Pneumothorax was detected in 39% of the patients, hemopneumothorax in 29%, hemothorax in 12%, flail chest in 9 %. Two had involvement of the heart and major vessels, 4 % had injury to the diaphragm and 5 % had multiple trauma. During treatment, 3% of all the patients were managed conservatively, 83% of patients required chest intubations, 6% needed ventilatory support and 8 % required thoracotomy. Complications were experienced in 28% of the patients of which 9% had pneumonias, 14% empyema and 5 % suffered from wound infections. The overall mortality was 7 %., Conclusion: This series showed the pattern of injuries following blunt and penetrating chest trauma. Furthermore, it was found that chest intubation and simple resuscitation was adequate for majority of the cases.

Shotgun injuries constitute an increasing surgical problem as they frequently lead to severe trauma disease and even to death. These injuries are mainly diagnosed in young people and are localized in limbs. Human life is in danger in case of shotgun injuries of the head (CNS), abdominal and thoracic cavities. Prognosis is worse in multiple shotgun lesions. The dominating cause of death in shotgun victims is hemorrhagic shock. Patient's life is potentially in a real danger and necessitates precise diagnostic and therapeutic management in the early stages following shotgun trauma, in the operating room and in the postoperative phase.

Background: Most seriously wounded US Army casualties from the Iraqi theater of operations come through Walter Reed Army Medical Center on their return to the United States. General surgery and orthopaedic surgery services have developed a multidisciplinary team approach to triage and treatment of incoming casualties., Study Design: Prospective database of returning casualties to Walter Reed Army Medical Center from Operation Iraqi Freedom (OIF) from March 1 to July 1, 2003., Results: Of 294 casualties seen, 119 were triaged to inpatient status and treated within 1 hour of arrival; mean age 26.6 +/- 6.2 years (range 23 to 37). Time from original battlefield injury was a mean of 8 days (range 3 to 28 days). Forty-six (39%) sustained gunshot wounds, 37 (31%) sustained blast and shrapnel injuries, and 41 (34%) had blunt/motor vehicle collision mechanisms. There were a total of 184 wounded locations in these 119 casualties; of these, there were 29 head and neck, 25 chest, 20 abdomen, 74 lower extremity, and 36 upper extremity. Twenty-eight casualties (23%) required emergent surgical procedures on the night of arrival. Another 30 (25%) required an urgent surgical procedure within 48 hours of arrival., Conclusions: Followup surgical procedures were urgently or emergently required in 43% of admitted battlefield casualties from OIF on transfer to Level V care in the continental United States. The injury pattern of wounds from this engagement is described. The Walter Reed Army Medical Center system of incoming battlefield casualty evaluation using multidisciplinary teams is successful in expediting care and ensuring evaluation of the full range of potential injuries.

DTPA clearance rate is a reliable index of alveolar epithelial permeability, and is a highly sensitive marker of pulmonary epithelial damage, even of mild degree. In this study, 99mTc-DTPA aerosol inhalation scintigraphy was used to assesss the pulmonary epithelial membrane permeability and to investigate the possible application of this permeability value as an indicator of early alveolar or interstitial changes in patients with blunt chest trauma. A total of 26 patients was chest trauma (4 female, 22 male, 31-80 yrs, mean age; 53+/-13 yrs) who were referred to the emergency department in our hospital participated in this tsudy. Technetium-99m diethylene triamine pentaacetic acid (DTPA) aerosol inhalation scintigraphy was performed on the first and thirtieth days after trauma. Clearance half times (T1/2) were calculated by placing a mono-exponential fit on the curves. Penetration index (PI) was calculated on the first-minute image. On the first day, mean T1/2 value of the whole lung was 63+/-19 minutes (min), and thirtieth day mean T1/2 value was 67+/-21 min. On the first day, mean PI values of the lung and 30th day mean PI value were 0.60+/-0.05, and 0.63+/-0.05, respectively. Significant changes were observed in radioaerosol clearance and penetration indices. Following chest trauma, clearance of 99mTc-DTPA increased owing to breakdown of the alveolar-capillary barrier. This increase in the epithelial permeability of the lung appears to be an early manifestation of lung disease that may lead to efficient therapy in the early phase.

Pulmonary injuries include a wide variety of clinical conditions. Most patients with blunt chest trauma can be managed with conservative treatment. Only about 10 to 15% of patients with severe chest injuries require major thoracotomy. Management of pulmonary contusion, pulmonary laceration, pneumothorax or hemothorax by oxygen inhalation, respirator assist and chest drainage can usually result in complete recovery. However, pulmonary injuries sometimes lapse into fatal condition if they are improperly treated. Open thoracotomy is required in cases with persistent massive air leakage or massive bleeding with the use of chest drainage. It is crucial to evaluate the extent and severity of the injuries based on chest X-ray and computed tomography (CT) findings for the proper initial treatment in patients with pulmonary injuries.

Computed tomography has had an increasing role in the evaluation of patients after blunt trauma. Important findings in thoracic trauma include acute traumatic aortic injury, pneumothorax, hemothorax, pulmonary contusions and lacerations, mediastinal hematoma, and diaphragmatic rupture. The solid abdominal viscera may lacerate; infarct; or suffer vascular, ductal, or pyelocalyceal disruption. The bladder and intestines may rupture. In abdominal pelvic trauma, the direction of applied force often results in an identifiable constellation of injuries. This article reviews how multidetector computed tomography (MDCT) is used in the trauma patient. Technical advances of increased cephalocaudad coverage speed and improved z-axis resolution intrinsic to MDCT, together with effective contrast utilization, make MDCT invaluable in the setting of trauma.

Background/purpose: Findings from studies in the trauma literature suggest that thoracic computed tomography (TCT) scanning should replace conventional radiographs as an initial imaging modality. Limited data exist on the clinical utility and cost of TCT scans in pediatric trauma. Our current practice is to obtain TCT scans in those children at risk for thoracic injures. The purpose of this study is to examine what additional information TCT provides, how frequently it results in a change in clinical management, and a cost/benefit analysis., Methods: Children 18 years old and younger that had both a Chest x-ray (CXR) and TCT scan in their initial workup were included. Indications for TCT scan were (1) any sign of thoracic injury on CXR, (2) pathologic findings on physical examination of the chest, and (3) high impact force to chest wall. A child may have had one or more indications for a TCT scan., Results: Between 1996 and 2000, 45 of 1,638 trauma patients met study criteria. Indications for TCT included thoracic injury on CXR (n = 27), findings on physical examination (n = 8) and high-impact force (n = 33). In 18 of the 45 (40%), injuries were detected with TCT imaging but not on CXR. These included contusions (n = 12), hemothorax (n = 6), pneumothorax (n = 5), widened mediastinum (n = 4), rib fractures (n = 2), diaphragmatic rupture (n = 1), and aortic injury (n = 1). In 8 patients (17.7%) TCT imaging resulted in a change in clinical management. These included insertion of a chest tube (n = 5) aortography (n = 2) and operation (n = 1). Age, sex, injury severity score, mechanism, and indication for TCT could not predict differences between TCT and CXR (P >.05). In our institution, the cost of a TCT is $200, and the patient charge is $906 ($94 per CXR). Based on our study data 200 TCTs would need to be done for each clinically significant change, increasing patient ($180,000) and hospital ($39,600) costs., Conclusions: Helical TCT is a highly sensitive imaging modality for the thoracic cavity; however, routine CXR still provides clinically valuable information for the initial trauma evaluation at minimal cost. TCT should be reserved for selected cases and not as a primary imaging tool., (Copyright 2003 Elsevier Inc. All rights reserved.)

Objective: To determine indications for emergency (immediate and urgent) thoracotomies in cases of penetrating and blunt chest traumas., Methods: We performed retrospective analysis of treatment methods and results, achieved in 2927 patients treated for chest traumas in 1987-2000., Results: Algorithms for decision making in surgical management of chest traumas are drawn. Indications for emergency (immediate and urgent) thoracotomies are determined. Immediate thoracotomy was performed in 17.2% and 0.2% of patients, suffering from penetrating and blunt chest trauma respectively. Urgent thoracotomy underwent 7.6% due to penetrating and 2.7% due to blunt chest trauma. Postoperative mortality rate was much higher after immediate (20.0%) and urgent (10.9%) thoracotomy performed due to blunt chest traumas. In cases of penetrating chest traumas postoperative mortality rate was 3.3% and 3.0% after immediate and urgent thoracotomies respectively., Conclusions: The effectiveness of surgical treatment of chest traumas depends on logical determination of indications for immediate or urgent thoracotomies. They should be undertaken in cases of severe damage of chest wall and/or internal organs and dangerous pathological syndromes.

Flail chest is associated with a higher morbidity compared with multiple rib fractures, and it requires early intubation. This was a prospective comparative uncontrolled study at an academic level 1 trauma center. Twenty-two patients with flail chest (FLAIL) were compared with 90 patients with more than two rib fractures but no flail chest (RIBS) to determine differences in outcomes such as mortality, significant respiratory complications (pneumonia and adult respiratory distress syndrome), need for mechanical ventilation, and length of hospital stay. Stepwise logistic regression identified independent risk factors of poor outcome. Despite similar age and rates of lung contusion and extrathoracic injury, FLAIL patients had a higher need for mechanical ventilation (86% versus 42%, P < 0.01), higher incidence of significant respiratory complications (64% versus 26%, P < 0.01), and longer hospital stay (28 +/- 21 versus 17 +/- 19 days, P = 0.04) compared with RIBS patients. Flail chest and extrathoracic injuries were independent risk factors of significant respiratory complications. Of 11 FLAIL patients who were not intubated on arrival, eight required intubation within the next 24 hours, often while receiving diagnostic studies in poorly monitored hospital areas; two of these patients suffered morbidity directly related to the delay in intubation. Three patients without associated injuries were managed successfully without intubation. Flail chest is an independent marker of poor outcome among patients with thoracic cage trauma. The majority of patients with flail chest need mechanical ventilatory support and develop significant respiratory complications. In the presence of associated injuries, intubation is unavoidable and should be done under controlled conditions early after arrival to avoid morbidity related to sudden respiratory decompensation.

Purpose: The chest injury pattern after a major earthquake is not well understood because data on the type of trauma and surgical intervention are limited. This study was conducted to analyze patients who sustained chest injury during the Marmara earthquake that struck Turkey on August 17, 1999 registering 7.4 on the Richter scale., Methods: The medical reports of 528 patients transported to a military hospital in the first 48 h after the earthquake were reviewed. Two chest surgeons examined these 528 patients, 19 of whom (4%) had suffered a major chest injury. We retrospectively evaluated the injury pattern, Abbreviated Injury Score (AIS), and Injury Severity Score (ISS) in these 19 patients., Results: Eight patients (42%) had isolated chest injuries and 11 (58%) had suffered injury to more than one organ system, including chest trauma. The mean AIS and ISS were assigned as 2.9 (SD: 1) and 22 (SD: 7), respectively. Three (16%) of the 19 patients died, all of whom had suffered multiple injuries. The mean ISS of these three patients was 28.7 (range 25-34). Chest injury after a major earthquake was associated with an overall mortality rate of 16%, but chest injury with multiple injuries and an ISS over 25 was associated with a mortality rate of 60%. All patients with isolated chest injuries survived., Conclusion: Coexistent trauma with chest injury and an ISS over 25 were defined as poor prognostic factors for patients rescued after a major earthquake.

The authors focused attention on objectivization of the severity of chest injuries and associated injuries using the Abbreviated Injury Scale (AIS) and the New Injury Severity Score (NISS). They evaluated injuries detected on post-mortem examination in subjects who died from the sequelae of injuries in the Faculty Hospital Prague 10. The group comprised a total of 90 subjects regardless of sex aged 17-94 years who died in the hospital in 1996-2000. Traffic injuries accounted for 70% deaths, other blunt injuries for 27.8% and only 2.2% were penetrating injuries of the chest. The mean AIS value of the chest was 3.7, the mean value of NISS was 50.7. The NISS value declined in relation to age of the deceased patients and the period of survival. The period of survival varied from 30 mins. to 136 days. The mean NISS value on survival up to 5 hours after injury was 55.0. On comparison of our group we found that the results were consistent with those of American studies.

Objective: To explore a way of guiding diagnosis and treatment of blunt and penetrating diaphragm injuries., Methods: According to injury violence, 46 chest trauma patients with diaphragm rupture were divided into two groups: a blunt injury group and a penetrating injury group. The injury condition and trauma scores between the two groups were compared and analyzed., Results: The incidence of blunt diaphragm injuries was lower than that of penetrating injuries (1.78% vs 8.53%, P <0.05). In the blunt injury group most patients had multiple injuries. Penetrating injuries developed more quickly than blunt injuries, and resulted in hemorrhagic shock in the early period. Trauma scores showed that there was no significant difference in the Revised Trauma Score (RTS), the Injury Severity Score (ISS) and thoracic Abbreviated Injury Scale (AIS) between the two groups (P<0.05), but the blunt injury group had lower Glasgow Coma Scale (GCS) and abdominal AIS than the penetrating group (P<0.0 5)., Conclusions: Blunt and penetrating diaphragm injuries have different clinical characteristics. So they should be dealt with differently to reduce the incidence of complication and improve prognosis.